Provider Demographics
NPI:1609989227
Name:DISSEN, LORI ANN (PTA, CWT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:DISSEN
Suffix:
Gender:F
Credentials:PTA, CWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1118
Mailing Address - Country:US
Mailing Address - Phone:920-687-1857
Mailing Address - Fax:920-831-7939
Practice Address - Street 1:10 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1658
Practice Address - Country:US
Practice Address - Phone:920-831-7902
Practice Address - Fax:920-831-7939
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI790-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant